Friday, August 16, 2013

Is the Government Getting in the Way of Treating Those With Severe Mental Illness?

So Twitter led me to Pete Earley's blog this morning, and that led me to The National Review for an article by E. Fuller Torrey and D. J. Jaffe -- see : After Newtown; The existing federal mental-health agency actually opposes efforts to treat mental illness.

To quote part of the article (surf over there for the whole thing), and note that SAMHSA is the government's Substance Abuse and Mental Health Service Administration:
What is severe mental illness? According to the National Advisory Mental Health Council, in response to an inquiry from Congress, severe mental illness includes schizophrenia, schizoaffective disorder, bipolar disorder, autism, and severe forms of depression, panic disorder, and obsessive-compulsive disorder. One measure of SAMHSA’s lack of interest in these disorders is its current three-year planning document, “Leading Change: A Plan for SAMHSA’s Roles and Actions 2011–2014.” Despite being 41,804 words in length and acknowledging that 9.8 million Americans are afflicted with what it refers to as “serious mental illness,” the SAMHSA plan includes not a single mention of schizophrenia, schizoaffective disorder, bipolar disorder, autism, or obsessive-compulsive disorder.
So, when it was asked to provide direction for the Biden Task Force, SAMHSA had nothing relevant to offer. It invited Daniel Fisher to provide testimony as a psychiatric expert. Fisher, director of the National Empowerment Center in Massachusetts, to which SAMHSA has given $330,000 a year for many years, has publicly stated that what is called severe mental illness is really just “severe emotional distress” and “a spiritual experience.” He also believes that “the covert mission of the mental health system . . . is social control.” Fisher’s former deputy similarly asserted that “mental illness is a coping mechanism, not a disease.”
Such views are consistent with views expressed by many invitees at SAMHSA’s annual conference. In 1995, for example, one speaker claimed that “schizophrenia is a healthy, valid, desirable condition — not a disorder . . . what is called schizophrenia in young people appears to be a healthy transformational process that should be facilitated instead of treated.” Similarly, in 2010, another speaker extolled mental illnesses as “extreme states of consciousness that are mad gifts to be nurtured and cultivated,” and he advised people with mental illnesses to stop taking their medication.
That the federal agency charged with reducing the impact of mental illness on America’s communities is sponsoring forums at which severe mental illness is extolled as a good thing has overtones of Lewis Carroll. But the situation is even more bizarre than that. SAMHSA’s only recommended “treatment” for all mental illnesses is the “recovery model” — in other words, everyone should simply recover. This is similar to the Caucus race in Alice in Wonderland in which the Dodo declares that “everybody has won, and all must have prizes.” The “recovery model” was officially defined by SAMHSA in 2004 as including ten “fundamental components,” the most important being that it is “self-directed by the individual, who defines his or her own life goals and designs a unique path towards those goals.” The “recovery model” includes no mention of the need for medication or other specific treatments. It makes no allowance for the fact that many individuals with severe mental illness are unaware of their own illness. This is an ideology, not a treatment. Under the “recovery model,” John Hinckley was defining his own life goal — the attention of Jodie Foster — when he shot President Reagan. Similarly, Cho, Loughner, Holmes, and Lanza were presumably attempting to define and achieve their life goals, too. Their actions would meet SAMHSA’s definition of “recovery.”


Alison Cummins said...


Presumably you are aware that the National Review has an explicit conservative agenda. It markets itself as a propaganda vehicle: “National Review and National Review Online are the benchmark vehicles for reaching those Republicans/conservatives who lead and shape opinion on all the important issues.” Any anti-government rants are to be examined carefully to see if they are actually true.

From the article: “That the federal agency charged with reducing the impact of mental illness on America’s communities is sponsoring forums at which severe mental illness is extolled as a good thing has overtones of Lewis Carroll.”

I actually see nothing wrong with that. There are times when you have a forum and lots of different people are going to present because you want to get a feel for the full range of ideas, and you want the best exponent of all the ideas so that when something seems to be a truly bad idea you know it’s not just because it was presented by someone naive and unprepared. If each presenter at a public forum were carefully vetted so that we knew they would only present one particular approved idea, then it wouldn’t be a public forum, would it? (That suggests what this thinks the purpose of a public forum is.) However, including the accusation that forums were held at which a wide variety of people spoke is consistent with a goal of persuading and not informing.

Given that this is the first time I’ve heard of SAMHSA (I’ll bet it’s the first time most readers have heard of it) I would need actual facts about its goals and effectiveness. If there’s a 41,804-word document that doesn’t contain the word “schizophrenia,” why not? I haven’t read it. Have you? Do you know why it doesn’t contain that word? Would it make sense given the goals of the document? Does replacing the list “schizophrenia, schizoaffective disorder, bipolar disorder, autism, and severe forms of depression, panic disorder, and obsessive-compulsive disorder” with the more manageable, “severe mental illness” detract from the usefulness of the document?

Without a lot more information, and *relevant* information (like the experiences of health-care providers trying to provide mental health care but prevented from doing so by the interference of SAMHSA), I have no way of answering your question.

So why did you ask it? Because you want us all to go out and take some courses in health administration and policy development?

Dinah said...

It was a rhetorical question.

Does it matter if a psychiatrist writes about his opinion of a government agency in a conservative publication? I'm all for freedom of speech, including the rights of those who do not share my beliefs to publish theirs. The National Review markets itself as a Republican biased publication, which is different then marketing themselves as a propaganda vehicle.

No politics here, except as it directly relates to psychiatry.


Alison Cummins said...

Rhetorical question — questions that aren’t actually meant to be answered because we already know the answer, like “is water wet?” or “do bears $h!t in the woods?” Except that I don’t know the answer. What is it?

“Does it matter if a psychiatrist writes about his opinion of a government agency in a conservative publication?” No. I’ve read some cool stuff in (for instance) Foreign Affairs, a magazine which advertizes drones and military colleges (and which I can therefore only imagine appeals primarily to a conservative reading public) but markets itself as “dedicated to improving the understanding of U.S. foreign policy and international affairs through the free exchange of ideas.” The National Review markets itself as a medium for influencing conservative opinion. Really, they aren’t the same kind of publication at all. The whole point of NR is to define and promote a particular type of conservative ideology and they are quite upfront about it. They aren’t about the free exchange of ideas which just happen to be primarily conservative. When a publication with a goal of promoting a particular ideology runs an article, the point of the article is to promote that ideology and not to discuss the ideas. If I were a psychiatrist with important ideas with data to back them up, I would first try to get my article published somewhere more respectable, where ideas are presented and discussed on their own merits. As a reader, I see this kind of placement and think that either 1) he couldn’t get his article published anywhere else or 2) the point of the article in the first place is not SAMHSA, it’s ideology. The National Review is not a place where one would expect ideas about psychiatry to be discussed knowledgeably, so an author can slip unsupported aguments in and expect not to be challenged.

In fact, as I read the article, the ideas were not discussed. Straw men were trotted out and accused; perfectly banal statements were presented as proof that The Goverment Is Inane.

I have no idea whether there is something rotten in the state of SAMHSA or not. Government bodies can be inane. Stopped clocks are right twice a day.

Can you tell me, as a clinician, whether SAMHSA has interfered with your treating those with severe mental illnss? That would be useful information to have. A data point.

Anonymous said...

Who gave that psychiatrist a microphone, let alone an MD? It seems obvious that medications prescribed (especially for a mental disorder or illness) should be handled on an individual, case by case basis between the doctor and patient. No one can make a blanket statement giving advice to any and all psychiatric patients regarding their treatment. If he thinks he can, well maybe he's gone off HIS medication.

Joel Hassman, MD said...

Gee, is this idea a surprise? Do any of you who practice in mental health care REALLY think that PPACA is going to improve mental health services once it is entrenched in society?

Dream on! Politicians have NO interest in mental health services, and their history of saying what people want to hear but doing what people don't want to get is the basis of their agenda.

Um, all you advocates out there, when you shake yourselves out of your partisan hypnotized states, be ready for what government controlled health care will do to your patients.

And to you as mental health care providers, it is only about 3 things to bureaucracy, cost, control, and minimizing effort.

If you think I am wrong, show me all those wonderful examples of how organized societies have done such wonderful and advanced efforts at treating the mentally ill.

I won't be holding my breath waiting for these rebuttals!

Oh, and these robot duplications asked of these replies of late, lame! One of the number pictures was blank!

Alison Cummins said...

Joel Hassman, MD:

Single-payer has done pretty well on the whole by me and my family.

It also reduces bureacracy enormously, judging from what I can see of the numbers of office staff that US MDs require just to manange insurance.

Anonymous said...

I only have to look at who authored the article to know all I need to know. The Treatment Advocacy Center is not going to be happy until everyone diagnosed with a serious mental illness has depot injections in their butt cheeks. I love their preventable tragedies database where they scour the newspapers for the words "mental illness" so they can blame any and every violent act on mental illness without bothering to gather the facts. All they need to know is that the words "mental illness" and "homeless" and/or "violence" appear in an article, and they have it all figured out. Their remedy is always force. I don't think they would know how to create a therapeutic alliance if their lives depended on it.

I have no doubt that SAMHSA wastes money, that's one thing our government has always done really well, but I'll take SAMHSA over TAC any day. TAC is scary, and they're probably just sour grapes that they aren't getting all the tax dollars.

Pseudo Kristen

ClinkShrink said...

Pseudo Kristen: I agree, their misappropriation of the news makes me want to rant. They mention Cho, Lanza, Loughner and Holmes without mentioning that there was never an actual trial in *ANY* of these cases to prove a connection between mental illness and the crime. The facts have never been heard. No mental state evidence has ever been presented. We'll never know. Yet TAC knows for certain that there was a connection, and that treatment would have prevented it.

Having an individual personal (non-professional) opinion about the news is one thing, but using that approach to push policy is another.

Joel Hassman, MD said...

response to Alison C:

Enjoy your single payer response for as long as it lasts as a benefit.

Sorry, while I might be in this living room of the shrink rap group, you need to hear the truth as it is:

You and your family are going to be screwed by the government, you just have blind trust in government that justifies your being screwed. The fact that the employees of government want out from the boundaries of the law show how f----d up it is. And keep that partisan agenda in place, they depend on people like you, until proven otherwise.

Hey, I am a harsh a--hole, and you know what, it's because I live in the world of reality, not partisan bulls--t.

And this site seems to be oblivious to what is coming. I don't care who calls me on it, the facts are what they are. The president is a fraud, the party he represents is a fraud, oh, and by the way, the other side of the polluted aisle of Republocrats, they are a fraud too.

We get the electorate we deserve as of now. Be independent and moderate, you'll be surprised what is really out there as America that is interested in the truth and facts. Democrats and Republicans, what a f-----g joke this system has turned out to be.

Hey, if this was my living room, I would tolerate the language. Because this crap dialogue from elected officials demands nothing less in honesty and directness!

Oh, thanks by the way for legitimate numbers and letters for once in submitting this response.

Anonymous said...

Clink and PK, to add to your excellent points, Cho and Holmes were already in the mental health system. And Lanza may have been although the evidence was not definite on.

Also, the guy who was responsible for Kendra's law was desperately trying to seek treatment but was turned away.

Yet, so many people constantly fall for Torey's misrepresentation that everyone with a mental illness needs to be locked up and get a shot of an antipsychotic in their rear end. It is extremely frightening and the press does nothing to correct these blatant misrepresentations.

On an off topic note, Dr. Hassman, I am sure the 43 million plus folks who are uninsured or whom can't access necessary medical care due to unaffordable high deductible policies would love to hear what you propose instead of the Canadian single payer plan. With all due respect, I am getting tired of political rants when people are dying from lack of health insurance.

Apologies to the shrink rappers for the last part of my comment but I couldn't let Dr. Hassman's comment go without a response.

Dinah said...

My only direct relationship with SAMHSA was when I was part of their Katrina Assistance Project, and I wanted to link to the article I wrote on that, but it seems to have vanished. Even then, I recall I wrote about how I wasn't sure I was worth what the government spent on me (and I was a volunteer, but they paid my flight/food allowance/room & board.

I didn't like the article because it seems Torrey wants to go knocking on door, drag out all the untreated mentally ill folks who might someday commit dangerous acts, and stick them in hospitals to evaluate them. It's just a weird idea.

Joel Hassman, MD said...

to anonymous 2 comments above:

Umm, people die because they die. Sometimes, all the health care options in the world won't stop that from happening. And the point is simply this, giving everyone health care coverage does not make the system better, does not make society better, and certainly does not improve culture.

People should have access to health care, never have argued otherwise, but, all you altruistic and selfless people out there, when does accountability and responsibility for appropriate choice and actions be called out?

There are too many people out there who truly think the health care system is infinite in resources and options. Wow, what is the color of the sky in this world you all live in holding this attitude?

Keep thinking PPACA will be this wonderful law. And that is the key word here, "LAW". I guess oblivious delusions are fun.

While they last!

Nathan said...

I used to be an evaluator for a SAMHSA funded grant related to sexual health. They have such a wide reach and are accountable to HHS and Congress. Like most public and many third sector organizations, because of the large amount of money they are allotted and spend, their higher-ups are more interested that they spend their money as planned and that they spend all of the money they were allotted. They, like other government health agencies, are transitioning to a more outcomes-approach to their funding (putting money where it in garners the most social value). This is a good thing. Hopefully it will help fund more evidence-supported work and SAMHSA will find and model effective local organizations/practitioners/advocates/groups to be more strategic and helpful.

As for leaving out SMIs in their big document, Insel and the NIMH no longer are putting any stock in those labels. It doesn't surprise me that that SAMHSA would not conceive of mental health disorders in a way that the NIMH is refusing to recognize and research. Probably a better sign of cross-agency alignment that SAMSHA used to have trouble with.

And what's wrong with a treatment model that is “self-directed by the individual, who defines his or her own life goals and designs a unique path towards those goals.” That allows individuals to make decisions about their own care, choosing appropriate treatments that are most meaningful to them. If people with SMIs are so unaware, that forced treatment is the only option you have available and SAMHSA I doubt is in the business of funding such treatments. Or, it is conceivable that someone with an "SMI" who does not believe themselves "ill," is able to recognize things in their life that can be improved through certain treatments or processes and can still get a lot of value through that self-directed process.

The recovery model is not "everyone should simply recover." It is finding ways to make living meaningful and engaging. Isn't this what psychiatrists usually go for, I hope? If that means taking meds it can mean that, it can also entail a lot of things.

Finally, disorder, illness, coping mechanism, transformative process, extreme state, or whatever, we don't have a valid epistemology of what we usually call mental illness. A recovery oriented approach would allow for a lot of potential meaning for what we call things, as what we call things may be more helpful or more harmful for different folks. If someone wants to say they are ill because of a yet unknown biological process of mental illness and take medications that certainly do not work to remedy that biological process but can produce effects that some people prefer to alternatives, great. Why does everybody who is experiencing severe distress have to?

Anonymous said...

I think TAC's speech is dangerous for a lot of people with severe mental illness, because I think it scares them further away from treatment that could potentially help them. I remember when my therapist was trying to get me to see a psychiatrist she knew, and every time I heard representatives of TAC on tv, the internet, or read an article by them, they made me even more adamant that I wouldn't go. It took a whole lot of convincing and reassurance that the psychiatrist she was recommending did not support TAC's agenda. I had already had a bad experience with a "my way or else" kind of doctor and that didn't work out well.

So, I have a lot of concern that when this is the image of psychiatry that gets presented in the media over and over again, it's very scary to people. They might as well play One Flew Over a Cuckoos's Nest repeatedly, because when I listen to those guys I see Nurse Ratched's face.

Hopefully, people who need treatment but hear TAC's fiery rhetoric and think that's what psychiatry is like will find this blog and realize that psychiatrists care about their patients and even talk about ducks.


Anonymous said...

Apparently, I cannot spell tonight.

One Flew Over the Cuckoo's Nest

Medusa said...

I have sometimes wondered what would happen if we simply left government out of healthcare completely AND cut out insurance companies. I have wondered if that would increase access to care, lower prices, and allow docs to be less restricted.

Though in the case of the really severely mentally ill, that might not be such a good idea. I have a feeling a lot of them can't afford care, so they would have to be covered by the government. So sad.

Skizzy said...

Schizophrenia is a healthy, valid, desirable condition? Wow, I never got that memo. Yes it is very healthy to stop eating and bathing so you can stare at the wall all day and listen to people that are not there. So desirable. Pffffft